Bayshore Nursing & Rehab
Bayshore Nursing & Rehab in GLENDALE, WI — inspection on April 30, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 04/30/26 at 1:45 PM, with Administrator and SSD, the Administrator indicated there was an incident on 2/11/26 between R9 and R8 in which R8 hit R9 in the face.
The SSD stated that since the resident-to-resident altercation on 02/11/26 with R9, R8 had been on 1:1 supervision.
R8 was discharged on 04/17/26.
Review of the facility's undated policy titled Abuse/Neglect/Exploitation provided by the facility revealed. It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse.
525371 04/30/2026
Bayshore Nursing & Rehab 1300 West Silver Spring Dr Glendale, WI 53209
Review of the Elopement Off Premises Report dated 12/12/25 and provided by the Administrator,
Review of R6's Care Plan located under the Care Plan tab of the EMR revealed R6 had a Court Ordered Guardian initiated 07/09/25 and last revised 04/18/26 indicated resident was not permitted to leave the facility independently. R6 was at risk for elopement due to impaired judgment and unsafe decision-making, with the goal of not having any incidents of elopement Since the elopement incident dated 12/12/25, R6's Care Plan did not address that R6's guardian approved for R6's to have planned outings to the soup kitchen and the intervention of the facility escort going with R6 and remaining with R6 while at the soup kitchen.
During an interview on 04/28/26 at 1:29 PM, R6 indicated the Administrator has made arrangements for her to go to the soup kitchen three times a week.
During an interview on 04/29/26 at 2:41 PM, SSD said she was not able to find anything in R6's care plan for R6 to go to the soup kitchen and the facility escort to remain with her while on the outing.
During an interview on 04/30/26 at 12:47 PM, when asked about care planning for R6 and going to the soup kitchen, the ADON confirmed that R6's care plan does not address R6 going on outings to the soup kitchen three times a week with a facility escort.
525371 04/30/2026
Bayshore Nursing & Rehab 1300 West Silver Spring Dr Glendale, WI 53209
Review of the facility's policy titled, Medication Errors dated 2025 and provided by the Administrator documented, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors.
The policy defined Medication error as the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order. or accepted professional standards and principles which apply to professional providing services.
Under the heading Policy Explanation and Compliance Guidelines indicated, 1.
The facility shall ensure medications will be administered as follows: a.
According to physician's orders, c. In accordance with accepted standards and principles which apply to professionals providing services. 7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information:.Right resident.
525371 04/30/2026
Bayshore Nursing & Rehab 1300 West Silver Spring Dr Glendale, WI 53209
Review of the facility's undated policy titled, Elopement provided by the Administrator indicated, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.
Review of the facility's undated policy titled, Policy Explanation and Compliance Guidelines the policy indicated .3.
The facility is equipped with door locks/alarms to help avoid elopements. 4.
Alarms are not a replacement for necessary supervision.6.
Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: b.
The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. d.
Adequate supervision will be provided to help prevent accidents or elopements. e.
Charge nurses and unit managers will monitor the implementation of interventions, response to interventions and document accordingly. 7.
Procedure for Locating Missing Resident: a.
Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g., internal alert code). b.
The designated facility staff will look for the resident.8.
Procedure Post-Elopement: d.
The resident and family/authorized representative will be included in the plan of care.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.